The Journal of Emergency Medicine

Editorial Board

2010-07-01

Issue Highlights

2010-07-01

Partial Contents of Volume 39, Number 2

2010-07-01

Burns in the Emergency Department: A National Perspective

Breena R. Taira, Adam J. Singer, Henry C. Thode, Christopher Lee — 2008-09-01

Abstract: Background: Burns are a common cause of injury presenting to the Emergency Department (ED). Several reports state that admission for and mortality from burn injury are declining. Total visits to the ED, however, have increased. Objectives: The objective of this study was to determine the number and trends over time of patients presenting to the ED for burn injury. Methods: The study was a retrospective analysis of National Hospital Ambulatory Medical Care Survey databases for 1996–2005 available from the Centers for Disease Control and Prevention. Subjects were patients with a first diagnosis of a burn. Patient weights in the database were used to obtain estimated national values. Measures used were estimated total numbers and percentages of patients by year. Trends from 1996 through 2005 were examined overall and by demographic factors and injury characteristics. Linear regression was used to evaluate trends. Results: There was a significantly decreasing trend in ED burn visits from 1996 to 2000 (614,745 to 433,681 visits), but no apparent trend for the years 2000 to 2005. Annually, about 60% of ED burn patients were male, and about half were between the ages of 19 and 44 years. Less than 5% of burns were third degree or full thickness injuries. Admissions per year were stable at 5%. The most common causes of burn injury were contact with a hot liquid and contact with a hot object, and the most common body region affected was the upper extremities (40% each year), followed by burns to the head/face/neck. Use of medications showed no trends over time. Conclusions: ED visits for burn injuries have been decreasing; however, patterns of cause, admission, and treatment show no consistent temporal change.

The Presence of Urinary Nitrites Is a Significant Predictor of Pediatric Urinary Tract Infection Susceptibility to First- and Third-Generation Cephalosporins

Dany Weisz, Jamie A. Seabrook, Rodrick K. Lim — 2008-09-01

Abstract: Background: Previous studies in adults have refuted the use of nitrites as a predictor of bacterial resistance to both trimethoprim-sulfamethoxazole and cephalosporins. Some centers now consider first-line outpatient therapy with an oral third-generation cephalosporin appropriate for young children. Objective: The objective of this study was to determine if nitrite-negative pediatric urinary tract infections (UTIs) were more likely than nitrite-positive UTIs to be resistant to cephalosporins. This may enable physicians to adjust antimicrobial therapy before patients leave the Emergency Department (ED) to avoid the complications of ineffectively treated pediatric UTIs. Methods: A retrospective chart review examined, over a 9-month period, 173 pediatric patients who were diagnosed with a clinical UTI in the ED and who also had a positive urine culture and a recorded dipstick at the time of visit. The chi-squared test and Fisher's exact test were used to compare nitrite-negative vs. nitrite-positive UTIs for resistance to third-generation cephalosporins and other empiric antimicrobials. Results: For third-generation cephalosporins, 1.4% of nitrite-positive UTIs were resistant, whereas 14.4% of nitrite-negative UTIs were resistant (95% confidence interval [CI] −0.22 to −0.05). For first-generation cephalosporins, 8.4% were resistant in the nitrite-positive group, compared to 22.2% in the nitrite-negative group (95% CI −0.24 to −0.03). Conclusion: The absence of urinary nitrites is a significant indicator for potential resistance to cephalosporins in pediatric UTIs. Due to low levels of pediatric UTI resistance, cephalosporins continue to represent useful empiric therapy in the general pediatric population. However, in high-risk patients, physicians may opt to alter their empiric choice of antibiotic based on the presence of urinary nitrites.

Evaluating the Sensitivity of Visual Xanthochromia in Patients with Subarachnoid Hemorrhage

Sanjay Arora, Stuart P. Swadron, Vinoo Dissanayake — 2008-06-24

Abstract: Combined computed tomography and cerebrospinal fluid (CSF) analysis has been shown to be 100% sensitive for detecting subarachnoid hemorrhage (SAH) when CSF is obtained between 12 h and 2 weeks from time of headache onset and spectrophotometry is used to evaluate CSF for xanthochromia. Because most hospitals do not use spectrophotometry, we sought to evaluate the sensitivity of CSF analysis for xanthochromia by visual inspection. We retrospectively identified all patients seen in the Emergency Department (ED) with an ED discharge diagnosis of SAH from June 1993 to November 2005. A structured chart review was performed on all patients with the additional billed procedure charge for “lumbar puncture” or “spinal tap.” Data collected included: CSF color, time from headache onset to CSF collection, and confirmation of SAH by advanced imaging. There were 1323 patients diagnosed with SAH, and 102 of these also had CSF collected. Of these, 81 charts were available for review. By predetermined protocol, 35 were excluded for lack of a report of CSF color, 1 was excluded because the time from headache onset to CSF collection was < 12 h, and 26 were excluded for lack of documentation of a definitive imaging study. Of the remaining 19, 9 were found to have xanthochromic CSF and 10 were found to have colorless CSF, resulting in a sensitivity for visual inspection of CSF of 47.3% (95% confidence interval 24.4–71.1%). Visual inspection of CSF supernatant for xanthochromia lacks the sensitivity necessary to reliably exclude the diagnosis of SAH.

Emergency Physician Ability to Predict Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections

Dick C. Kuo, Rose M. Chasm, Michael D. Witting — 2008-06-03

Abstract: Methicillin-resistant Staphylococcus aureus (MRSA) has a high prevalence in Emergency Departments (EDs). The objective of this study was to determine the ability of emergency physicians to predict MRSA infection in purulent wounds. A prospective observational study was conducted in an urban, tertiary academic center in ED patients presenting with purulent wounds and abscesses that received wound culture. Physicians completed a questionnaire with patient demographic data and their own suspicion for MRSA infection in eligible patients. For emergency physician ability to predict positive culture for MRSA, sensitivities, specificities, and positive and negative likelihood ratios (LRs) were calculated. Risk factors were assessed for statistical significance using a chi-squared test with p < 0.05. There were 176 patients enrolled, and 19 were eliminated for incomplete data. Physician suspicion of MRSA had a sensitivity of 80% (95% confidence interval [CI] 71%–87%) and a specificity of 23.6% (95% CI 14%–37%) for the presence of MRSA on wound culture with a positive LR of 1.0 (95% CI 0.9–1.3) and a negative LR of 0.8 (95% CI 0.5–1.3). Prevalence was 64%. Only intravenous drug use was significantly associated with MRSA. Emergency physician's suspicion of MRSA infection is a poor predictor of MRSA infection.

Delayed Presentation of Traumatic Diaphragmatic Rupture

Lisa R. Walchalk, Stephen C. Stanfield — 2008-05-20

Abstract: We present the case of a 57-year-old woman who suffered a delayed presentation of a traumatic diaphragmatic rupture (TDR). Because TDR is frequently missed on initial presentation, a delay between trauma and diagnosis can present a unique diagnostic dilemma for the emergency physician. Important historical clues and physical examination findings are the keys to making this diagnosis.

Left Ventricular Bullet Embolus: A Case Report and Review of the Literature

Joseph Galante, Jason A. London — 2008-07-10

Abstract: Missile embolization to the heart occurs infrequently in penetrating trauma. The lack of a concentrated experience at any single institution contributes to the controversies pertaining to diagnostic and therapeutic approaches to management. The objective of this study was to describe a case of a left ventricular bullet embolus and provide a detailed diagnostic and therapeutic framework for management of intracardiac projectiles. Initial management of a patient with suspected intracardiac projectiles is dictated by his or her hemodynamic status. Unstable patients generally require operative intervention. In the stable patient, associated injuries must be sought. Localization of the projectile can be aided by echocardiogram, fluoroscopy, or angiography. Definitive management is individualized, and can range from observation to percutaneous or operative extraction. The decision depends on the cardiac chamber involved, the patients' symptoms, and the projectile's size, shape, and location within the chamber. Missile embolus to the heart is an infrequent occurrence, but when found presents a diagnostic and therapeutic challenge. Management strategies should be individualized. A detailed management algorithm is provided.

Hepatic Artery Aneurysm Erosion into the Stomach: An Unusual Cause of Gastrointestinal Bleeding

2008-10-24

Abstract: Background: Hepatic artery aneurysms are the second most common visceral aneurysms. The natural history of hepatic artery aneurysms typically results in enlargement, rupture, and life-threatening hemorrhage. Atherosclerosis, traditionally, has been the most common cause of hepatic artery aneurysm. Objective: A case of a hepatic artery aneurysm invading the stomach is presented to draw attention to the clinical presentation of this potentially catastrophic entity. Case Report: A 74-year-old man presented to the Emergency Department (ED) with hematemesis. He was hemodynamically stable with a hemoglobin of 10.5. Abdominal CT imaging revealed a hepatic artery aneurysm that eroded into the stomach. The erosion was successfully repaired operatively and the aneurysm was embolized. Conclusion: The most common symptom is epigastric pain. The clinical and radiological findings of a hepatic artery aneurysm eroding into the stomach with subsequent upper and lower gastrointestinal hemorrhage, as highlighted in the case reported, have received little prior attention in the medical literature.

Meningitis and Subgaleal, Subdural, Epidural Empyema Due to Pasteurella Multocida

Hüseyin Per, Sefer Kumandaş, Hakan Gümüş, Mustafa K. Öztürk, Abdulhakim Çoşkun — 2008-05-20

Abstract: Pasteurella is a Gram-negative coccobacillus found in 70–90% of oral cavities of cats, and as well, is isolated from the digestive systems of dogs, rats, rabbits, monkeys, and other animals. Pasteurella multocida has been known to cause infections in humans, the most familiar being soft tissue infection after animal bites. However, this organism may affect a variety of systems, causing serious disease. Pasteurella multocida can cause septic arthritis, osteomyelitis, pneumonia, endocarditis, meningitis, and septicemia. We report a case of bacterial meningitis, subgaleal, subdural, and epidural empyema due to Pasteurella multocida by a rabbit licking that resulted in neurological complications and a prolonged recovery period.

Fatal Pulmonary Edema After Acute Occupational Exposure to Nitric Acid

Christine M. Murphy, Halleh Akbarnia, S. Rutherfoord Rose — 2008-10-09

Abstract: Background: Nitric acid (HNO3) is a solution of nitrogen dioxide (NO2) in water commonly used as an industrial chemical and cleaner. Oxides of nitrogen liberated as nitric acid interact with the environment to cause inhalation injuries. The coexistence of HNO3 with varying oxides of nitrogen likely results in the large continuum of symptoms related to HNO3 exposure and varying times of onset—acute, subacute, and delayed. Furthermore, dyspnea and evidence of acute lung injury may not occur for several hours after exposure and can lead to rapidly progressive acute respiratory distress syndrome (ARDS). Objectives: This case illustrates to physicians and occupational health personnel that HNO3 inhalation may initially appear benign and that onset of severe effects may be delayed. Case Report: A 66-year-old man developed delayed-onset pulmonary edema, ARDS, and fatal circulatory collapse 53 h after occupational exposure to HNO3. Conclusion: This case serves to increase awareness among emergency physicians, as well as occupational health personnel, that patients exposed to HNO3 may initially be asymptomatic. Patients should be evaluated and observed regardless of the severity or benign nature of symptoms, which occur immediately after exposure, as the most severe symptoms are often delayed in onset and rapidly progressive.

Comparison of Toxicity of Acute Overdoses with Citalopram and Escitalopram

2008-12-12

Abstract: Background: Seizures and QTc prolongation are associated with citalopram poisoning; however, overdose experience with escitalopram is more limited. Objectives: The goals of this study were to compare citalopram's vs. escitalopram's clinical effects in overdose, including the incidence of seizures. Methods: A retrospective review was conducted for single-substance acute overdoses with citalopram and escitalopram, managed in hospitals, that were reported to six U.S. poison centers from 2002–2005. Results: There were 374 citalopram and 421 escitalopram overdose cases. Gender and ages were similar between the two, with 68–70% females and a median age of 20 years for citalopram and 18 years for escitalopram. Median dose by history was 310 mg for citalopram and 130 mg for escitalopram. More serious outcomes were associated with citalopram overdoses (p < 0.001). Most frequently reported clinical effects with citalopram and escitalopram were tachycardia, drowsiness, hypertension, and vomiting. Seizures (30 vs. 1, respectively, p < 0.001) and tremor (32 vs. 13, respectively, p = 0.001) were more common with citalopram. QTc prolongation occurred in 14 citalopram cases and 7 escitalopram cases (p = 0.109). There was an association between increasing dose and severity of outcome for citalopram (p < 0.001) and escitalopram (p = 0.011). In children < 6 years old, 12 of 66 citalopram and 5 of 57 escitalopram cases experienced toxicity, such as drowsiness, nausea/vomiting, and tachycardia. There were no seizures in this age group. Conclusions: Escitalopram seems to be less toxic than citalopram after an acute overdose; seizures and tremors were more common with citalopram. Initial management of overdoses should include seizure precautions for citalopram and cardiac monitoring for both drugs.

Resident Involvement in Civilian Tactical Emergency Medicine

Mario Luis Ramirez, Corey M. Slovis — 2009-08-17

Abstract: Background: Tactical emergency medicine services (TEMS) has emerged as a specialized niche within the field of emergency medicine. With increasing demand for physician participation in civilian tactical teams, there will be efforts by residents to become involved at earlier points in their clinical training. Objectives: This article discusses resident involvement with a civilian TEMS unit and provides five maxims for emergency physicians to better understand the difference between working in the emergency department or with emergency medical services vs. in a TEMS environment. Discussion: Differences between TEMS and other trauma life support models, institutional and political barriers likely to be encountered by the resident, the value of preventive medicine and the role of the physician in long-term tactical operations, opportunities for subspecialty growth, and the role of operational security are all discussed in detail. Conclusion: Tactical emergency medicine is a specialty that utilizes the full array of the emergency physician's skill set. It is also a field that is ripe for continued expansion, but the resident looking to become involved with a team should be aware of the requirements necessary to do so and the obstacles likely to be encountered along the way.

The Disposition Decision on Emergency Department Patients with Chest Pain is Affected by the Results of Multi-Detector Computed Axial Tomography Scan of the Coronary Arteries

2009-06-05

Abstract: Background: Few data exist on the frequency with which multidetector computed axial tomography (MDCT) scan of the coronary arteries changes the admission decisions of emergency physicians (EP) caring for patients with possible acute coronary syndrome (ACS). We measured if and how often these changes in decision-making would occur. Methods: The theoretical dispositions of 27 emergency department patients who presented with possible ACS were determined by four board-certified EPs after case presentations. Paired disposition decisions were made before and after knowledge of the MDCT scan results. Patients were selected from a sample of 103 from a prior study. Results: The study included 27 patients with a mean age of 55 ± 9 years; 58% were male. The low-, intermediate-, and high-risk MDCT scan results were evenly distributed, as were the original providers' standard clinical risk assessments of ACS. Three patients had ACS and all were admitted both before and after review of MDCT scan results. Among 24 patients without ACS, a decision to admit was changed to discharge in 16 of 90 admission decisions (18%, 95% confidence interval [CI] 10–26%). Among 6 patients with projected discharges, 2 were inappropriately admitted after review of MDCT scan results. The odds ratio of discharge for patients without ACS increased by 3.95 (95% CI 1.96–7.95) after introduction of the MDCT scan results. Conclusion: An MDCT scan of the coronary arteries will likely change emergency physicians' decisions on the disposition of patients presenting with possible ACS, many to appropriate discharges but also a minority to inappropriate admissions.

Emergency Medicine Resident Performed Bedside Ultrasonography of the Gallbladder in Non-Fasted Healthy Volunteers

2009-01-27

Abstract: Background: Gallbladder ultrasonography is a commonly performed test in the emergency department. It is unknown whether a non-fasting state alters the visualization of the gallbladder by emergency medicine (EM) residents. Objectives: We conducted this study to determine whether EM residents are able to visualize the gallbladder in volunteers who have recently consumed a fatty meal. Methods: This study used a prospective, single-blinded, randomized controlled design. Initial scans were performed on fasting volunteers. A fatty meal was then consumed. Thirty minutes after eating, a different resident, who was unaware of whether the volunteer had eaten or fasted, performed a second scan. To control for operator bias, 10% of subjects remained fasting between scans. Student's paired-samples t-test, Pearson's chi-squared, and McNemar test were determined as appropriate. Results: A total of 92 scans from 46 volunteers were analyzed. EM residents were able to visualize the gallbladder in all 40 pre-prandial scans (100%) and all 40 post-prandial scans (100%). Gallbladder area as measured in the longitudinal axis decreased 20% from a mean baseline of 11.58 ± 4.86 cm2 (95% confidence interval [CI] 11.17–12.98) to 9.2 ± 5.04 cm2 (95% CI 7.74–10.66, p = 0.0009) after food intake. Total time to scan for the fasting volunteers (110.2 s, 95% CI 84.34–136) did not change significantly from non-fasting volunteers (129.7 s, 95% CI 110.29–149.01, p = 0.153). Conclusions: EM residents are able to visualize the gallbladder in non-fasted healthy volunteers.

Effects of Vein Width and Depth on Ultrasound-Guided Peripheral Intravenous Success Rates

Michael D. Witting, Stephen M. Schenkel, Benjamin J. Lawner, Brian D. Euerle — 2009-03-09

Abstract: Background: Increasing numbers of operators are learning to use ultrasound to guide peripheral intravenous (i.v.) catheter insertion in patients with difficult access. Unfortunately, failed cutaneous punctures are common. Some veins seen on ultrasound may be better choices than others. Objectives: To estimate the effects of vein width and depth on the probability of success in ultrasound-guided i.v. catheter insertion. Methods: We prospectively collected data from attempts at ultrasound-guided venous catheter insertion between the antecubital fossa and mid-humerus. Each ultrasound machine's ruler function was used to determine depth from the skin to the closest vein edge and that vein's largest diameter. Success was defined as being able to freely withdraw blood or inject saline after the first skin puncture, considering each encounter independently. We calculated relative success rates, confidence intervals, and p values using reference groups selected by histogram analysis. Results: Thirty-five operators recorded 180 encounters; 100 (56%) were successful on the first skin puncture, and 152 (84%) were eventually successful. Success rates were not linearly related to vein width or depth. Success rates were higher for veins with diameter ≥ 0.4 cm vs. those < 0.4 cm (63% [78/124] vs. 39% [22/56], relative success 1.6 [95% confidence interval (CI) 1.1–2.3], p = 0.005) and for veins of depth 0.3–1.5 cm vs. veins of depth < 0.3 or > 1.5 cm (58% [96/165] vs. 27% [4/15], relative success 2.2 [95% CI 0.9–5.1], p = 0.04). Conclusion: Success rates are higher in larger veins (≥ 0.4 cm) and veins at moderate depth (0.3–1.5 cm).

Comparison of Ultrasound-Guided and Standard Landmark Techniques for Knee Arthrocentesis

Jennifer L. Wiler, Thomas G. Costantino, Lisa Filippone, Wayne Satz — 2008-12-08

Abstract: Background: Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. Objective: To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. Methods: This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. Results: There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. Secondary Endpoints: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61–4.80) cm vs. LM 5.19 (95% CI 3.94–6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37–1.97) vs. 2.11 (95% CI 1.79–2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36–13.80) min vs. LM 13.37 (95% CI 9.83–16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45–55.21) mL vs. LM 34.7 (95% CI 26.09–43.32) mL; p = 0.17. Conclusion: US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.

Superior Cluneal Nerve Block for Treatment of Buttock Abscesses in the Emergency Department

Andrew Herring, Dan D. Price, Arun Nagdev, Barry Simon — 2009-11-18

Abstract: Background: The buttock is a common location for cutaneous abscesses among patients presenting for emergency department care. Procedural pain management sufficient to permit adequate incision and drainage often requires moderate sedation or general anesthesia. Discussion: We describe a patient with a buttock abscess who successfully underwent incision and drainage with a regional superior cluneal nerve blockade instead of moderate sedation. Conclusions: Our experience suggests that superior cluneal nerve blockade may reduce the need for procedural sedation, expedite care, and reduce costs for some patients presenting with buttock abscesses.

A New Maneuver for Endotracheal Tube Insertion During Difficult Glidescope Intubation

Ron M. Walls, M. Samuels-Kalow, A. Perkins — 2010-01-25

Abstract: Background: The GlideScope® Video Laryngoscope (Verathon, Bothell, WA) is a video laryngoscopy system that can be used for routine intubation, but is also commonly used as an alternative for difficult or failed airways. Previous reports have identified a very high incidence of grade 1 and grade 2 Cormack-Lehane glottic views, but despite these high-grade views, intubation is sometimes difficult due to the angle of insertion and shape of the endotracheal tube. Several maneuvers have been reported to increase the likelihood of successful endotracheal tube placement in these uncommon cases of failure. Case Report: We report the case of a patient who could not be intubated with the GlideScope® despite an easily obtained grade 1 laryngoscopic view. The impediment to intubation was identified as a sharp angulation of the trachea with respect to the larynx, such that the trachea formed a steep posterior angle with the laryngeal/glottic axis. Intubation was achieved using a previously unreported maneuver, in which the endotracheal tube with a sharply curved malleable stylet was inserted through the glottis, and then rotated 180° to permit passage down the trachea. Discussion and Conclusion: We believe that this maneuver may be useful in other cases of failed GlideScope® intubation, when a high-grade laryngeal view is obtained but tube passage is not possible due to a sharp posterior angulation of the trachea.

The Feasibility and Accuracy of Point-of-Care Lactate Measurement in Emergency Department Patients with Suspected Infection

2009-09-01

Abstract: Background: Prior studies show that lactate is a useful prognostic marker in sepsis. Objective: To study the feasibility and accuracy of a point-of-care (POC) analyzer capable of performing bedside serum lactate measurements; and to determine if other measurements (pH, base excess) are predictive of mortality. Methods: Design: prospective cohort study of adult (age 18 years or older) Emergency Department (ED) patients with suspected infection during the study period of May 2006 through March 2007. Setting: A 55,000-annual-visit urban tertiary care ED. Intervention: A point-of-care device (i-STAT, Abbott Point of Care Inc., Princeton, NJ) was deployed using a standardized training and quality assurance process. Using POC testing, we measured serum lactate, pH, and base excess, as well as concomitant lactate measurement via a central laboratory. Statistics: Area under the curve (AUC) for receiver operator characteristic curve, Bland-Altman statistics along with a correlation coefficient, and relative risk with 95% confidence intervals reported. Results: There were 699 patients enrolled, of whom 34 (4.9%) died. The AUCs for mortality prediction were: POC lactate 0.72, laboratory lactate 0.70, pH measurement 0.60, and base excess 0.60. Bland-Altman showed that POC lactate was, on average, 0.32 (95% confidence interval −0.35–0.98) lower than laboratory lactate, with agreement kappa = 0.97. Conclusions: A point-of-care testing device provides a reliable and feasible way to measure serum lactate at the bedside. The pH and base excess were less helpful.

Encapsulating Peritoneal Sclerosis

Michael L. Sternberg, Amy Woodward — 2008-06-24

A 36-year-old woman presented to the ED with a chief complaint of acute-onset nausea, vomiting, and crampy periumbilical abdominal pain requiring parenteral narcotics to control. Past medical history was significant for multiple similar episodes and history of peritoneal dialysis for end-stage renal failure. Abdominal X-ray study and computed tomography (CT) scan demonstrated diffuse peritoneal calcifications ().

Clenched Fist Injury

Michael L. Sternberg, Tracy Jacobs — 2008-06-24

An 18-year-old man presented to the Emergency Department with complaint of right hand swelling and severe pain. Two days prior, he was involved in an altercation during which he struck another man in the mouth, sustaining a small puncture wound to the second metacarpophalangeal (MCP) joint (). The patient was admitted for intravenous antibiotics and surgical consultation.

An Unusual Upper Airway Foreign Body

Michelle P. Tomassi, Lorraine G. Thibodeau — 2008-07-10

A 44-year-old man presented to our tertiary care Emergency Department after having been escorted off a casino tour bus for heavy alcohol intoxication. The patient's past medical history was significant for asthma and a “speech impediment” per friends. He took no medications and had no drug allergies.

From the Editor: An Open Letter to Our Authors and Readers

Stephen R. Hayden — 2010-05-04

I wanted to communicate with all of you regarding some exciting changes at the Journal of Emergency Medicine. I also wanted to be open and honest regarding an ongoing issue with a backlog of accepted articles in press and to let you know what we are doing about it.

Should the Recommended Dose of Epinephrine for Severe Croup be Changed?

Ozlem Teksam — 2008-12-22

A 2-year-old girl was admitted to our pediatric emergency department (PED) with complaints of barking cough, fever, and respiratory difficulty. On physical examination, she had audible stridor, intercostal retractions, cyanosis, and lethargy. Air entrance was diminished bilaterally. Oxygen saturation was 82%. The pediatric emergency physician made a diagnosis of severe croup, and Westley croup score was 17. However, foreign body aspiration was also included in the differential diagnosis due to the rapid onset of symptoms and findings of upper airway obstruction, although she had no history of foreign body aspiration. A chest X-ray study revealed subglottic narrowing on posterior-anterior view, but there was no finding of foreign body aspiration. After initial diagnosis, the patient was monitorized and oxygen was started. Dexamethasone 0.6 mg/kg was immediately injected intramuscularly and, simultaneously, 5 mL nebulized L-epinephrine at a ratio of 1:4000 (0.25 mg/mL) was started. She dramatically responded to the nebulized epinephrine in a few minutes. At 15 min after the first dose of epinephrine, her Westley croup score was 10. At the same time, she was considered for admission to the pediatric intensive care unit (PICU). At 30 and at 45 min, the Westley Croup Score was 3. Therefore, she did not need to be admitted to the PICU and repeated doses of epinephrine were not given. Finally, at 7 h, the Westley Croup score was 0. She was discharged from PED at 11 h and she was followed-up the next day.

Digoxin and Calcium: The Verdict is Still Out

Amit Gupta, Mark Su, Howard Greller, Nima Majlesi, Robert S. Hoffman — 2009-11-02

In their recent study, Levine et al. concluded that intravenous calcium may be safe in digoxin-poisoned patients (). However, several methodological concerns limit the validity of that conclusion. Recruitment bias should be considered in this retrospective chart review. Inclusion criteria were documented digoxin toxicity and a serum digoxin concentration > 2.0 ng/dL. As is known, signs and symptoms of digoxin toxicity are non-specific and can include lethargy, confusion, nausea, or anorexia (). These symptoms are also consistent with renal failure and hyperkalemia, and it is entirely unclear from the information presented which patients had renal insufficiency with numerically elevated digoxin concentrations and which had digoxin toxicity. Perhaps a more objective marker could have been selected, such as electrocardiogram changes consistent with cardiac glycoside toxicity. The appearance of an ectopic ventricular rhythm, such as a premature ventricular contraction, is the most frequent disturbance noted in digoxin toxicity (). Other electrocardiographic findings consistent with digoxin toxicity include bidirectional ventricular tachycardia, atrioventricular junctional blocks of varying degrees, atrial tachydysrhythmias with block, and delayed afterdepolarizations, which are not typically characteristic of hyperkalemia ().

Reply to Dr. Gupta and Colleagues

Michael Levine, Heikki Nikkanen, Daniel J. Pallin — 2009-08-25

We would like to thank Dr. Gupta for the insightful comments. He is correct that the symptoms associated with chronic digoxin toxicity are somewhat vague. It may be difficult to distinguish hyperkalemia due to renal insufficiency from digoxin-induced hyperkalemia in both retrospective reviews and in daily practice. All patients who were included in the study had digoxin toxicity documented as a formal diagnosis by an attending physician. We disagree that digoxin toxicity must be diagnosed electrocardiographically. Furthermore, it is well known that retrospective interpretation of electrocardiogram findings are notoriously inaccurate and should be avoided ().

Falling Ice and Snow Masses: A Rare Mechanism of Injury

2008-12-17

There are some rare types of traumas that can be seen only in certain conditions, regions, or climates (). In our region, the temperatures in the winter can be as low as −40°C, the snowfall rate is high, and there is a great variance in the temperatures between day and night. This causes rapid meltdown of snow during the daytime and refreezing at night, which leads to the formation of ice stalactites and huge ice and snow masses on the roofs of buildings. We describe a unique mechanism of injury for trauma, that is, falling ice and snow masses.

Emergency Department Patients Who Stay More Than 6 Hours Contribute to Crowding

2009-01-21

Abstract: Background: Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. Objectives: To describe patients who stay > 6 h in the ED and determine their association with measures of crowding. Methods: This was a retrospective, observational study carried out over 1 year at a single, urban, academic ED. Results: Of the 96,562 patients seen, 16,017 (17%) stayed > 6 h (51% admitted). When there was at least one patient staying > 6 h, 60% of the time there was at least one additional patient in the waiting room who could not be placed in an ED bed because none was open. The walk-out rate was 0.34 patients/hour when there were no patients staying in the ED > 6 h, vs. 0.77 patients/hour walking out when there were patients staying > 6 h in the ED (p < 0.001). When the ED contained more than 3 patients staying > 6 h, a trend was noted between increasing numbers of patients staying in the ED > 6 h and the percentage of time the ED was on ambulance diversion (p = 0.011). Conclusion: In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.

Comparison of Methods for Identifying Ano-Genital Injury After Consensual Intercourse

2009-02-17

Abstract: Background: Microtrauma occurs after consensual intercourse. Understanding the injury pattern from consensual intercourse may enlighten our understanding of the ano-genital injury after sexual assault. Objective: The purpose of this report is to compare consensual intercourse-related ano-genital injury prevalence by using three different forensic examination techniques: 1) direct visual inspection, 2) colposcopy, and 3) toluidine-blue contrast application. Methods: Using a descriptive, comparative design, 120 female volunteers, aged 21 years or older, were examined after consensual sexual intercourse using the above techniques. Ano-genital injuries were noted using the TEARS classification (Tears, Ecchymoses, Abrasions, Redness, and Swelling). Results: Direct visualization and colposcopy yielded similar ano-genital injury findings. However, more tears and abrasions of the external genitalia were identified with toluidine-blue than with direct visual inspection or colposcopy (p < 0.05). More tears were identified on the anus with toluidine-blue as compared to direct visualization (p < 0.05), but not colposcopy. Fewer ecchymoses were identified on the internal genitalia and fewer areas of redness were identified on both the external and internal genitalia when toluidine-blue was used, as compared to either direct visualization or colposcopy (p < 0.05). Conclusions: The scientific community needs to continue to build information about ano-genital injury prevalence after consensual sexual intercourse. Understanding the ano-genital injury patterns, including frequency and prevalence, that occur with consensual sexual intercourse will help to identify the difference between injury related to consensual vs. non-consensual sexual intercourse. At this time, toluidine-blue staining may add value to the sexual assault forensic examination. It is the health care provider's role to collect all possible evidence and the courts' role to determine what evidence is admissible and to ensure a rightful conviction.

American Academy of Emergency Medicine

2010-07-01

Pulse Oximetry Using a Disposable Finger Sensor Placed on the Forehead in Hypoxic Patients

Howard A. Smithline, Ned Rudnitzky, Sandy Macomber, Fidela S.J. Blank — 2009-05-01

Abstract: Background: Disposable pulse oximetry sensors designed for the finger are sometimes placed on the forehead. Although finger sensors have not been designed to accurately measure arterial oxygen saturation when placed on other body parts, they are used on the forehead when an oximetry waveform cannot be obtained from the finger. Objectives: The purpose of this prospective observational study was to measure the agreement between disposable transmittal sensors placed on the finger and the same sensors placed on the forehead. Methods: We used a convenience sample of hypoxic emergency department patients. Patients were attached to three oximeters: 1) a non-disposable finger sensor (reference); 2) a disposable finger sensor placed on the finger; and 3) a disposable finger sensor placed on the forehead. Data were analyzed using the Bland-Altman method. A difference of 5% was considered clinically significant. Results: Twenty-five patients were approached, and 20 were enrolled. Eleven of the patients had an absolute difference between the disposable finger sensor placed on the finger compared to the forehead ≥ 5%. Conclusion: Pulse oximetry measurements taken on the forehead using a disposable finger sensor were inaccurate in over half of the subjects. Therefore, disposable finger oximetry sensors should not be placed on the forehead.

Cameron L.R. Jones, Rimon Bengiamin — 2009-09-18

Challenger Fundamentals: EM Ultrasound is an interactive CD-ROM intended to teach emergency medicine providers point-of-care ultrasound basics. Proficiency in point-of-care ultrasound provides imaging quickly, may reduce the need for other diagnostic tests involving radiation, and expedites patient care. All three authors are well qualified, all with interests in ultrasound, including a fellowship director in emergency ultrasound, a residency director, and a senior member of the American Institute of Ultrasound in Medicine. The goals of the CD-ROM, as stated by the authors, are to present educational material on the technology and physics of ultrasound, sonographic anatomy, and scanning technique, as well as standard emergency ultrasound applications. It is intended to benefit emergency medicine practitioners by providing them with a valuable skill to use in their practice.

Kathleen A. Regacho — 2009-09-10

As Dolly Parton famously spouted, “Plastic surgeons are always making mountains out of molehills.” It's true that plastic surgeons augment physical appearance, and although I'd love to debate the merits of this, I'll save my op-ed piece for now. However, it is irrefutable that emergency medicine providers are often presented with plastic surgery emergencies, and when this happens, we share our colleagues' goals of providing excellent outcomes and appearances.

Hyperglycemia as a Predictor of Outcome During Non-Invasive Ventilation in Decompensated COPD: Chakrabarti B, Angus RM, Agarwal S, et.al. Thorax 2009;64:857–62

Colleen Foster — 2010-07-01

In this observational, prospective, cohort study, hyperglycemia and several other clinical variables were examined with regard to their impact on the success of non-invasive ventilation in patients presenting with chronic obstructive pulmonary disease exacerbation. Patients were prospectively identified at one academic hospital in Liverpool, UK. Inclusion criteria included the presence of predefined characteristics of chronic obstructive pulmonary disease (COPD) exacerbation or pneumonia in patients that required non-invasive ventilation within the first 24 h of their hospital admission. From the initial total of 107 episodes, 88 episodes were included in the study. The following variables were elicited and then analyzed to determine their correlation with success of non-invasive ventilation: age, gender, baseline pulmonary function, known diagnosis of diabetes, glucose level, arterial pH, arterial pCO2, arterial pO2, calculated bicarbonate, respiratory rate, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Charlson comorbidity index. Those identified as significant, with a p < 0.1, underwent further logistic regression. All of respiratory rate, blood glucose, and APACHE II scores proved to be independently associated with successful non-invasive ventilation. It was determined that a respiratory rate > 30 breaths/min combined with a glucose < 7 mmol/L predicted 97% success with non-invasive ventilation. When an APACHE II score < 16.5 was added to these two, the predicted success rose to 100%.

Expand the Pharyngitis Paradigm for Adolescents and Young Adults: Centor RM. Ann Intern Med 2009;151:812–5

Janetta Iwanicki — 2010-07-01

This review article highlights Fusobacterium necrophorum as an important and under-recognized etiology of infectious pharyngitis in adolescents and young adults. Previous studies and standard-of-care guidelines have focused primarily on treating streptococcal pharyngitis, with a goal of reducing post-streptococcal complications such as rheumatic fever. Many algorithms recommend that non-streptococcal pharyngitis should not be treated with antibiotics. The author suggests that pharyngitis caused by F. necrophorum should also be strongly considered for treatment with antibiotics. Three studies are cited suggesting that the overall prevalence of these bacteria in patients with clinical pharyngitis and tonsillitis is approximately 10%, very similar to the prevalence of Group A streptococcus in the same group. Treatment for F. necrophorum pharyngitis is penicillin with metronidazole, or clindamycin. The author notes that F. necrophorum is associated with a serious and potentially deadly complication, Lemierre syndrome. Lemierre syndrome is a septic and suppurative thrombophlebitis of the internal jugular vein associated with bacteremia and septic emboli to distant sites. The incidence of Lemierre syndrome per 100,000 patients with F. necrophorum pharyngitis (250) is greater than the incidence of acute rheumatic fever per 100,000 patients with streptococcal pharyngitis (50). Based on the prevalence of F. necrophorum pharyngitis and the estimated frequency of Lemierre syndrome as a consequence of this infection, the author concludes that treatment of F. necrophorum should be considered as part of the algorithm for pharyngitis, especially in cases where the patient appears systemically ill or has other signs or symptoms associated with Lemierre syndrome.

Cardiovascular Events Associated with Ipratropium Bromide in COPD: Ogale S, Lee T, Au D, Boudreau D, Sullivan S. Chest 2010;137:13–9

Charles M. Reynolds — 2010-07-01

In this large cohort study of 82,717 U.S. veterans with a new diagnosis of chronic obstructive pulmonary disease (COPD) in both the inpatient and outpatient setting, the authors evaluated the incidence of cardiovascular events (CVE) in patients exposed to inhaled anticholinergics (almost exclusively ipratropium bromide). A CVE was defined as a hospital admission for acute coronary syndrome, dysrhythmia, or heart failure. The cohort included U.S. veterans aged 40–100 years admitted to a Veterans Affairs (VA) hospital or seen in an outpatient clinic between October 1998 and September 2002 with a new primary diagnosis of COPD. Of the study group, 44% received anticholinergic medications at some point. Most of the individuals in the cohort (93%) received short-acting beta agonists. Over a total of 274,025 patient years, there were a total of 6234 CVEs. Incidence of CVEs was higher in those patients exposed to anticholinergics within 6 months compared to those who were not exposed. Overall, exposure to anticholinergic medications was associated with a 29% higher risk of CVEs over 1 year as compared to those who were not exposed. Increased risk was confined to those receiving anticholinergic medications within 6 months, and no increased risk was found in those who received anticholinergic medications more than 6 months before enrollment.

Reliability of Parent-Measured Axillary Temperatures: Klein M, DeWitt TG. Clin Pediatr (Phila) 2010;49:271–3

Colleen Foster — 2010-07-01

This was a prospective cohort study examining the discrepancy between temperatures measured in the axilla vs. those measured rectally, and assessing the reliability of axillary temperatures measured by parents vs. those measured by medical staff. The study was designed around two hypotheses: first, that the discrepancy between measured rectal and axillary temperatures will persist despite the use of new digital thermometers; and secondly, that temperatures measured by parents are not as reliable as those measured by medical staff. Participants were selected from multiple centers including outpatient suburban private practice clinics, urban health centers, urgent care centers, and the children's hospital emergency department. Children over 2 months of age and weighing 16–28 pounds were eligible for inclusion. Selected participants were divided into two groups based on the presence or absence of fever, which was defined as a rectal temperature > 38.0°C. They used a calibrated digital thermometer to measure rectal and axillary temperatures at presentation and 1 and 2 h later. Both medical providers and parents measured axillary temperatures. Parents were given no instruction regarding the method for measurement, but 50% of the time they obtained their measurement after the medical provider first performed theirs. Demographic data about the participants found that there were no statistically significant differences between the febrile and afebrile groups on the basis of gender, weight, and age. Analysis of the temperature data demonstrated a small difference between rectal and axillary temperature measurements, with rectal temperatures being a mean of 0.3–0.4° higher than axillary. This difference, although not statistically significant, was greater in the febrile group. There was no significant difference between the measurements taken by parents vs. those taken by staff members.

Copeptin: A Novel, Independent Prognostic Marker in Patients with Ischemic Stroke: Katan M, Fluri F, Morgenthaler NG, et al. Ann Neurol 2009;66:799–808

Janetta Iwanicki — 2010-07-01

Copeptin is a fragment of provasopression, the biochemical precursor to vasopressin. As vasopressin levels increase in the setting of physiologic stress, copeptin levels increase in the systemic circulation. This prospective observational study measured copeptin levels in plasma obtained on admission from 362 consecutive patients with an acute ischemic stroke with symptoms of < 72 h duration during a 1-year period at a single hospital. A total of 605 patients were evaluated for inclusion, with 243 patients excluded for discovery of an alternative diagnosis, onset of symptoms more than 72 h before arrival, or no informed consent. The primary outcome measured was favorable functional outcome after 90 days, defined as a modified Rankin score of 0 to 2. The secondary outcome measured was mortality from all causes within 90 days. Overall, patients with unfavorable functional outcomes at 90 days and patients who did not survive past 90 days both had elevated copeptin levels compared to those patients with favorable outcomes (19.4 vs. 8.2 for functional outcome, p < 0.001; 35.6 vs. 9.5 for mortality, p < 0.001). The copeptin levels were also found to correlate with the National Institutes of Health Stroke Scale (NIHSS) score, with an NIHSS score of 0–6 points having an average copeptin level of 8.6, an NIHSS score of 7–15 having an average copeptin level of 15.8, and an NIHSS score of > 15 having an average copeptin level of 30.1. The predictive accuracy of the copeptin level was measured using the area under the receiver operating characteristic curve (AUC). The AUC for copeptin alone for predicting poor outcome as measured by modified Rankin score of > 2 was 0.73, compared to an AUC for NIHSS score of 0.75. The combined score of both copeptin level and NIHSS score performed better than either individual measure, with an AUC of 0.79 (p < 0.001). When examining the prediction of all-cause 90-day mortality, copeptin level had an AUC of 0.83, and NIHSS score had an AUC of 0.85. Once again, the combined score significantly improved the accuracy, as compared to NIHSS score alone, with an AUC of 0.89 (p = 0.02). The authors conclude that the addition of copeptin level to NIHSS score improves the prognostic accuracy of clinicians when predicting the outcome of patients with ischemic stroke.

Ethnic Differences in Parental Perceptions and Management of Childhood Fever: Cohee L, Crocetti M, Serwint J, Sabath B, Kapoor S. Clin Pediatr (Phila) 2010;49:221–7

Charles M. Reynolds — 2010-07-01

In this cross-sectional study, the authors surveyed a convenience sample of 487 parents with children enrolled in two urban hospital-based clinics in Baltimore, MD regarding their perceptions and management of fever. The authors were specifically interested in parents' definition of fever, level of concern, and management of fever. Only 44% of parents identified fever temperature as 38–41.67°C (100.4–107°F); 67% of parents treated fevers < 38°C (100.4°F). Eighty-five percent of parents would awaken a child to treat a fever, and 68% of parents were very worried about fevers. Cross-sectional analysis showed that Caucasians were more likely to identify non-febrile and febrile temperatures correctly (92% and 53%, respectively), whereas Latinos were least likely (38% and 33%, respectively). Latinos were more likely to frequently check temperature, most likely to believe that fever can rise above 43.33°C (110°F), and least likely to alternate acetaminophen and ibuprofen for treatment of fever. African-Americans were most likely to believe that a temperature of < 37.78°C (100°F) can cause harm (38%, vs. 18% in Caucasians and 11% in Latinos).

Noninvasive Ventilation Reduces Intubation in Chest Trauma-Related Hypoxemia: A Randomized Clinical Trial: Hernandez G, Fernandez R, Lopez-Reina P, et al. Chest 2009;137:74–80

Colleen Foster — 2010-07-01

In this prospective, randomized, controlled trial, adult patients with severe thoracic trauma were assigned to receive either non-invasive positive pressure ventilation or high-flow oxygen, with the primary outcome of interest being the incidence of endotracheal intubation. Inclusion criteria included adult patients admitted to the intensive care unit (ICU) for severe thoracic trauma who were < 48 h from their initial trauma and had > 8 h of hypoxemia. Specific parameters were defined to identify respiratory failure and the need for intubation. In patients that did not have a contraindication, analgesia was provided in the form of regional anesthesia, usually epidural blocks. Respiratory rate, heart rate, blood pressure, and arterial blood gases were measured at 1 h, 2 h, 3–4 h, 6–8 h, 12 h, 24 h, and 72 h after presentation. Secondary endpoints were pneumothorax, pneumonia, sepsis, ICU days, in-hospital days, and mortality. The data were examined at two pre-set interim analysis points. A total of 79 patients were screened, and 50 patients were included in data analysis, with 25 patients in each of the two groups. The results of this analysis at the second of the two interim points indicated that non-invasive positive pressure ventilation significantly decreased the rate of endotracheal intubation (3/25 vs. 10/25), and the study was prematurely terminated. This relationship was consistent after adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, and the presence of congestive heart failure. Additionally, those patients receiving non-invasive positive pressure ventilation had a decreased number of in-hospital days, but did not have a decreased number of days spent in the ICU. Due to the low number of patients that required intubation in the positive pressure group, there was not sufficient power for analysis of early predictors of non-invasive ventilation failure. Limitations identified by the authors included that they did not reach the desired sample size and the impossibility to blind caregivers to group assignment. They also stated that congestive heart failure was four times more common in the positive pressure group, and that this is a condition that is recognized to benefit from positive pressure ventilation. However, even when this entity was controlled for, the benefit continued to persist. The authors concluded that in patients with hypoxia related to severe thoracic trauma, the use of non-invasive mechanical ventilation reduced the need for intubation and length of stay.

Inhaled Corticosteroids vs Placebo for Preventing COPD Exacerbations: A Systematic Review and Metaregression of Randomized Controlled Trials: Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Chest 2010;137:318–25

Janetta Iwanicki — 2010-07-01

This systematic review and meta-regression analysis aimed to determine the efficacy of using inhaled corticosteroids to prevent chronic obstructive pulmonary disease (COPD) exacerbations as compared to placebo. The authors performed a search of the Cochrane Central Database of Controlled Trials, PubMed, and EmBase that yielded a total of 11 studies that met the search criteria, with 8164 study participants (4241 received inhaled corticosteroids, 3923 placebo). Significant heterogeneity of studies was noted. There were differences in study medications, doses of medication used, presence or absence of systemic steroids, and even in the definition of COPD exacerbations. The combined study population characteristics showed a mean forced expiratory volume over 1 second (FEV1) value of < 50% in 7 of 11 studies, and a predominance of male study participants. Overall, an 18% relative risk (RR) reduction in occurrence of exacerbations was found with the use of inhaled steroids compared to the use of placebo (RR 0.82; 95% confidence interval [CI] 0.73–0.92). The authors performed sensitivity analysis to examine the degree of benefit associated with variation in baseline FEV1, finding that benefit occurred only in patients with FEV1 < 50% (RR 0.79; 95% CI 0.69–0.89). In contrast, their meta-regression showed that the reduction of risk of COPD exacerbation was not related to baseline FEV1 (slope = 0.0057, intercept = 20.4598, Q = 10.06, P = 0.36). The authors conclude that there is modest benefit only to the use of inhaled corticosteroids to prevent COPD exacerbation, and that although the subgroup analysis shows increased benefit in patients with FEV1 < 50%, their meta-regression did not support this conclusion.

Risk of Fatal Dysrhythmic Events in Long QT Syndrome Patients After Syncope: Jons C, Moss A, Goldenberg I, et al. J Am Coll Cardiol 2010;55:783–8

Charles M. Reynolds — 2010-07-01

In this retrospective observational study of 1059 patients from the International Long QT Syndrome (LQTS) Registry, the authors analyzed risk factors for sudden cardiac death (SCD) and severe dysrhythmic events (SDE) in a database of patients with LQTS. The study group included 1059 LQTS registry patients from 764 families with corrected QT interval (QTc) of ≥ 450 milliseconds (ms). In these patients, beta-blocker therapy was initiated at the discretion of the patient's physician. The primary endpoint was SDE or SCD. A total of 210 SDEs were captured, of which 39% occurred during beta-blocker therapy. The incidence of syncope in these patients was approximately 5% per year, whereas the incidence of SCD was 1.9% per year. In patients with LQTS, a non-fatal event was the strongest predictor of a fatal event, with those who have experienced syncope having a 5% incidence of SCD (compared to 2.9% in those not experiencing syncope). The authors found that patients who experienced syncope after the initiation of treatment with beta-blockers had a 3.59-fold higher risk of SDE (p < 0.001, 95% confidence interval [CI] 2.25–5.74). Those patients who had multiple episodes of syncope before initiation of beta-blocker therapy had a hazard ratio of 1.96 for SDE (p < 0.001, 95% CI 1.37–2.82). Female patients aged 14 to 40 years had a 1.86-fold higher risk (p < 0.001, 95% CI 1.40–2.49), whereas those with QTc > 500 ms had a hazard ratio of 1.76 (p < 0.001, 95% CI 1.32–2.27).

Fast Food and Neighborhood Stroke Risk: Morgenstern LB, Escobar JD, Sanchez BN, et al. Ann Neurol 2009;66:165–70

Colleen Foster — 2010-07-01

This observational cohort study evaluated the association between ischemic stroke and the density of fast food restaurants in an area of Southern Texas. Study subjects were those with cerebrovascular disease identified from the records from all local hospitals, neurology offices, and the county coroner. Neighborhoods were assessed for the number and location of fast food restaurants. The distance from the homes of the stroke victims to fast food restaurants was calculated. A neighborhood score representing neighborhood disadvantage was calculated using median household income, median value of occupied housing units, percent of households receiving interest, divided or net rental income, percent of adults who completed high school, percent of adults who completed college, and percent of adults whose occupation was classified as managerial or professional. Demographic information such as age, gender, race, and neighborhood scores were examined with regard to stroke risk for the neighborhood, as was the number of fast food restaurants. A total of 1246 stroke cases were identified. The association between the number of fast food restaurants and stroke was found to be statistically significant, with the risk of stroke within a neighborhood increasing by 1% for every fast food restaurant in the neighborhood, even after adjusting for demographics and neighborhood score. The relative risk for neighborhoods in the 75th percentile for number of fast food restaurants vs. those in the 25th percentile was 1.13 (95% confidence interval 1.02–1.25). There was also an association between neighborhood score and fast food restaurants, although this did not reach statistical significance.

The ROSE (Risk Stratification of Syncope in the Emergency Department) Study: Reed MJ, Newby DE, Coull AJ, et al. J Am Coll Cardiol 2010;55:713–21

Janetta Iwanicki — 2010-07-01

This single-center prospective observational study was designed to develop a clinical decision rule to predict serious outcomes and all-cause mortality within 1 month of emergency department (ED) presentation with a syncopal episode. Serious outcomes were defined as acute myocardial infarction, life-threatening cardiac dysrhythmia, need for pacemaker or implantable defibrillator placement, pulmonary embolism, acute stroke, acute intracranial hemorrhage, significant hemorrhage requiring blood transfusion, need for acute surgical intervention, or need for acute endoscopic procedure. A total of 550 patients were included in the derivation cohort, with a subsequent additional 550 patients included in the validation cohort. Examination of the data for the initial 550 patients using logistic regression analysis identified seven presenting features of patient history, examination, or laboratory values associated with serious outcomes or death: B-type natriuretic peptide level ≥ 300 pg/mL, bradycardia ≤ 50 in the ED or pre-hospital, rectal examination showing fecal occult blood, anemia with hemoglobin ≤ 90 g/L, chest pain associated with syncope, electrocardiogram showing Q wave (not in lead III), and oxygen saturation ≤ 94% on room air. The rule recommends that any patient with one or more of these criteria be admitted to the hospital for observation. When applied to the validation cohort, the rule was found to have a sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of 87.2%, 65.5%, 16.5% and 98.5%, and 2.5 and 0.2, respectively. The authors conclude that using this rule in the validation cohort would have resulted in 80 fewer admissions, no additional deaths, and missing five serious outcomes (elevated troponin, ventricular tachycardia, subarachnoid hemorrhage, basal ganglia hemorrhage, and gastric ulcer). They suggest that their rule is favorable compared to prior clinical decision rules regarding syncope because the ROSE rule is able to avoid admissions without compromising sensitivity. However, no specific numeric comparisons are provided.

Superficial Venous Thrombosis and Venous Thromboembolism: A Large, Prospective Epidemiologic Study: Decouses H, Quere I, Presles E, et al. Ann Intern Med 2010;152:218–24

Charles M. Reynolds — 2010-07-01

In this multicenter prospective, observational, cohort study conducted in a French subspecialist referral setting, the authors evaluated the incidence of concomitant deep venous thrombosis (DVT) and pulmonary embolism (PE) in 844 consecutive patients with symptomatic superficial venous thrombosis (SVT) of the lower extremities measuring at least 5 cm on compression ultrasonography. Among this cohort of patients presenting with SVT, 210 (24.9%) had either DVT (198 subjects, 23.5%) or PE (33 subjects, 15.7%) at the time of presentation with SVT. Patients with SVT were treated in a heterogeneous fashion by vascular specialists: among the 600 patients with DVT or PE, 62.9% received low-molecular-weight heparins (LMWH) at treatment doses and 36.7% received LMWH at prophylactic doses. Almost all (97.7%) received compression stockings, whereas 47.2% received topical non-steroidal anti-inflammatory medications. Despite treatment for SVT, 18 subjects developed either DVT (15 subjects, 2.8%; 95% confidence interval [CI] 1.4–4.2), or PE (3 subjects, 0.5%; 95% CI 0–1.2). The authors also considered 28 subjects with either extension or recurrence of SVT to be part of the thromboembolic complications group.

Calendar of Events

2010-07-01

Metformin Overdose With a Resultant Serum pH of 6.59: Survival Without Sequalae

2008-03-17

Abstract: Metformin, widely used in the treatment of diabetes mellitus, is known to cause lactic acidosis in both therapeutic use and after an overdose. We report the case of a 40-year-old woman who claimed to have ingested between 75 and 100 grams of metformin and subsequently developed severe lactic acidosis. She eventually developed a peak serum lactate level of 40.0 mmol/L and a serum pH nadir of 6.59 and became obtunded, hypotensive, and hypothermic. After aggressive supportive therapy with mechanical ventilation, vasopressor agents, sodium bicarbonate, and hemodialysis, her metabolic derangements steadily improved and she made a complete recovery without any residual sequelae. Her admission serum metformin concentration was later determined to be 160 μg/mL (therapeutic range is 1–2 μg/mL). There are several case reports and case series describing lactic acidosis secondary to metformin ingestion, although the exact mechanism remains unclear. The overall management of metformin overdose is reviewed. This case represents the largest reported amount of ingested metformin, the lowest serum pH, and the highest serum lactate concentration in any intentional metformin overdose survivor in the literature. Despite potentially lethal metabolic derangements, such patients can survive with aggressive supportive care.

Tracheal Intubation Prevented With Administration of Fab Antivenom After Severe Crotaline Envenomation

Vikhyat S. Bebarta, Robinson M. Ferre, Michael Peck — 2008-08-26

Abstract: Background: Crotaline snake envenomations are common, but severe crotaline envenomations are infrequent. Death from severe envenomation is usually from upper airway edema and respiratory failure. Published reports of severe respiratory compromise and anaphylactoid reactions are rare. Currently, FabAV (Crotalidae polyvalent immune Fab [Ovine] [CroFab]) is the mainstay of crotaline envenomation treatment; however, FabAV has been approved for only mild and moderate envenomations. Case report: We describe a case of a male with severe systemic effects and airway compromise after crotaline envenomation. The patient's systemic effects and upper airway edema substantially improved after antivenom infusion and before epinephrine administration. Endotracheal intubation was averted, clinical deterioration was avoided, and improvement occurred after prompt FabAV use. Conclusion: Fab antivenom likely prevented endotracheal intubation in our case of severe crotaline envenomation.

Emphysematous Pyelonephritis with Emphysematous Pancreatitis

Kushaljit Singh Sodhi, Anupam Lal, Sameer Vyas, S. Verma, N. Khandelwal — 2008-07-10

Emphysematous pyelonephritis (EPN) is a rare, fulminant gas-forming infection of the renal parenchyma that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue (). EPN occurs typically (> 90%) in diabetic patients. However, it is also seen in non-diabetic patients with obstruction of the renal or ureteric system (). Diagnosis of EPN is based on radiological confirmation of gas within the kidney or collecting system. It has a high mortality rate and needs early emergency management. Milder forms of the disease are managed successfully with a combination of antibiotics and percutaneous drainage. However, early nephrectomy is recommended in more severe cases or in patients with septic shock. Our case was unusual in that there was involvement of both kidneys and the pancreas, resulting in emphysematous pyelonephritis and pancreatitis.

Focal Mass-Like Opacity on Chest Radiography: Round Pneumonia

2008-07-24

A 26-year-old woman presented to the Emergency Department (ED) with a complaint of fever and myalgia for 2 days. There was no history of cough or sputum production. She had no prior surgical or medical problems. Her blood pressure was 108/70 mm Hg, pulse rate 156 beats/min, temperature 39.7°C, respiratory rate 16 breaths/min, and oxygen saturation 96% on room air. The physical examination was also significant for mild decreased breath sounds over the right mid chest; the remainder of the physical examination was unremarkable. Intravenous access was obtained, and laboratory tests were performed. The electrolytes, glucose, renal function, and liver function tests were all within normal limits. The white blood cell count was 6600/cc3. A chest radiograph revealed a spherical pattern with a homogeneous 4.5 × 4.5 cm diameter opacification on the right middle lobe (). A computed axial tomography (CT) scan of the chest revealed well-marginated air space consolidation in the right middle lobe, consistent with pneumonia (). Empiric antibiotic treatment was initiated according to current recommendations, using a macrolide, in this case, clarithromycin 500 mg by mouth twice a day for 10 days. On ambulatory follow-up after 10 days, the patient was symptom-free.

A Pregnant Woman with Vaginal Bleeding

Corey M. Long — 2009-10-05

A 34-year-old woman presented to the Emergency Department (ED) complaining of vaginal bleeding. In the prior 2 days she had used eight pads, and noted mild abdominal cramping, nausea, and vomiting. She denied fever and dysuria. Her last menstrual period was approximately 10 weeks prior, and a quantitative serum human chorionic gonadotropin (hCG) level was >100,000 mIU/mL. An ED ultrasound study was performed (), demonstrating a heterogeneous uterus with multiple hypoechoic cystic structures. There was no evidence of an intrauterine pregnancy, although there was suspicion of a molar pregnancy. Tissue pathology from a dilatation and curettage procedure confirmed a complete hydatidiform mole.